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Τετάρτη 6 Φεβρουαρίου 2019
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Medical Education Texts
Objective Skills Clinical Examination: Every Day in the Field of Practice
Assessing Competence in Medicine and Other Health Professions
In Response
No abstract available
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A Multivariable Model Predictive of Unplanned Postoperative Intubation in Infant Surgical Patients
BACKGROUND: Unplanned postoperative intubation is an important quality indicator, and is associated with significantly increased mortality in children. Infant patients are more likely than older pediatric patients to experience unplanned postoperative intubation, yet the literature provides few characterizations of this outcome in our youngest patients. The objective of this study was to identify risk factors for unplanned postoperative intubation and to develop a scoring system to predict this complication in infants undergoing major surgical procedures. METHODS: In this retrospective cohort study, The National Surgical Quality Improvement Program-Pediatric database was surveyed for all infants who underwent noncardiac surgery between January 1, 2012 and December 31, 2015 (derivation cohort, n = 56,962) and between January 1 and December 31, 2016 (validation cohort, n = 20,559). Demographic and perioperative clinical characteristics were examined in association with our primary outcome of unplanned postoperative intubation within 30 days of surgery. Risk factors were analyzed in the derivation cohort (2012–2015 data) using multivariable logistic regression with stepwise selection. Parameters from the final model were used to create a scoring system for predicting unplanned postoperative intubation. Data from the validation cohort were utilized to assess the performance of the scoring system using the area under the receiver operating characteristic curve. RESULTS: In the derivation cohort, 2.2% of the infants experienced unplanned postoperative intubation within 30 days of surgery. Of the 14 risk factors identified in multivariable analysis, 10 (age, prematurity, American Society of Anesthesiologists physical status, inpatient status, operative time >120 minutes, cardiac disease, malignancy, hematologic disorder, oxygen supplementation, and nutritional support) were included in the final multivariable logistic regression model to create the risk score. The area under the receiver operating characteristic curve of the final model was 0.86 (95% CI, 0.85–0.87) for the derivation cohort and 0.83 (95% CI, 0.82–0.85) for the validation cohort. CONCLUSIONS: About 1 in 50 infants undergoing major surgical procedures experiences unplanned postoperative intubation. Our scoring system based on routinely collected perioperative assessment data can predict risk in infants with good accuracy. Further investigation should assess the clinical utility of the scoring system for risk stratification and improvement in perioperative care quality and patient outcomes. Accepted for publication December 20, 2018. Funding: L.D.E. is supported by an institutional training grant from the National Institutes of Health, T32GM008464-26. M.K. is supported by the National Center for Advancing Translational Sciences, National Institutes of Health through Grant Number KL2TR001874. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://bit.ly/KegmMq). Reprints will not be available from the authors. Address correspondence to Lisa D. Eisler, MD, Department of Anesthesiology, Columbia University Medical Center, 622 W 168th St, PH 5, Suite 505C, New York, NY 10032. Address e-mail to LDL2113@cumc.columbia.edu. © 2019 International Anesthesia Research Society
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Cataract Surgery: When the Eyes Are Bigger Than the Stomach
No abstract available
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Effectiveness of Magnesium in Preventing Shivering in Surgical Patients: A Systematic Review and Meta-analysis
BACKGROUND: Clinical trials regarding the antishivering effect of perioperative magnesium have produced inconsistent results. We conducted a systematic review and meta-analysis with Trial Sequential Analysis to evaluate the effect of perioperative magnesium on prevention of shivering. METHODS: We searched PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, and 2 registry sites for randomized clinical trials that compared the administration of magnesium to a placebo or no treatment in patients undergoing surgeries. The primary outcome of this meta-analysis was the incidence of shivering. The incidence of shivering was combined as a risk ratio with 95% CI using a random-effect model. The effect of the route of administration was evaluated in a subgroup analysis, and Trial Sequential Analysis with a risk of type 1 error of 5% and power of 90% was performed. The quality of each included trial was evaluated, and the quality of evidence was assessed using the Grading of Recommendation Assessment, Development, and Evaluation approach. We also assessed adverse events. RESULTS: Sixty-four trials and 4303 patients (2300 and 2003 patients in magnesium and control groups, respectively) were included. The overall incidence of shivering was 9.9% in the magnesium group and 23.0% in the control group (risk ratio, 0.42; 95% CI, 0.33–0.52). Subgroup analysis revealed that the incidence of shivering was lower with IV (risk ratio, 0.29; 95% CI, 0.29–0.54; Grading of Recommendation Assessment, Development, and Evaluation, moderate), epidural (risk ratio, 0.24; 95% CI, 0.13–0.43; Grading of Recommendation Assessment, Development, and Evaluation, low), and intrathecal administration (risk ratio, 0.64; 95% CI, 0.43–0.96; Grading of Recommendation Assessment, Development, and Evaluation, moderate). Only trials with low risk of bias were included for Trial Sequential Analysis. The Z-cumulative curve for IV magnesium crossed the Trial Sequential Analysis monitoring boundary for benefit even though only 34.9% of the target sample size had been reached. The Z-cumulative curve for epidural or intrathecal administration did not cross the Trial Sequential Analysis monitoring boundary for benefit. No increase in adverse events was reported. CONCLUSIONS: Perioperative IV administration of magnesium effectively reduced shivering and Trial Sequential Analysis suggested that no more trials are required to confirm that IV magnesium effectively reduces shivering. Accepted for publication December 12, 2018. Funding: This study was supported by funding from the Department of Anesthesiology, Yokohama City University, Yokohama, Japan. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://bit.ly/KegmMq). Trial registry number: CRD42018083337 (PROSPERO). URL: http://bit.ly/2Gu1mjl. Reprints will not be available from the authors. Address correspondence to Hiromasa Kawakami, MD, Department of Anesthesiology, Yokohama City University Medical Center, Urafunecho 4-57 Minamiku Yokohama, Kanagawa 232-0024, Japan. Address e-mail to hiro.k210@gmail.com. © 2019 International Anesthesia Research Society
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Editorial by US Food and Drug Administration Attorney Fails to Address Core and Ongoing Issues Seen With Vasopressin Market
No abstract available
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Perioperative Care for Adolescents Undergoing Major Surgery: A Biopsychosocial Conceptual Framework
No abstract available
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American Society for Enhanced Recovery and Perioperative Quality Initiative-4 Joint Consensus Statement on Persistent Postoperative Opioid Use: Definition, Incidence, Risk Factors, and Health Care System Initiatives
Persistent postoperative opioid use is thought to contribute to the ongoing opioid epidemic in the United States. However, efforts to study and address the issue have been stymied by the lack of a standard definition, which has also hampered efforts to measure the incidence of and risk factors for persistent postoperative opioid use. The objective of this systematic review is to (1) determine a clinically relevant definition of persistent postoperative opioid use, and (2) characterize its incidence and risk factors for several common surgeries. Our approach leveraged a group of international experts from the Perioperative Quality Initiative-4, a consensus-building conference that included representation from anesthesiology, surgery, and nursing. A search of the medical literature yielded 46 articles addressing persistent postoperative opioid use in adults after arthroplasty, abdominopelvic surgery, spine surgery, thoracic surgery, mastectomy, and thoracic surgery. In opioid-naive patients, the overall incidence ranged from 2% to 6% based on moderate-level evidence. However, patients who use opioids preoperatively had an incidence of >30%. Preoperative opioid use, depression, factors associated with the diagnosis of substance use disorder, preoperative pain, and tobacco use were reported risk factors. In addition, while anxiety, sex, and psychotropic prescription are associated with persistent postoperative opioid use, these reports are based on lower level evidence. While few articles addressed the health policy or prescriber characteristics that influence persistent postoperative opioid use, efforts to modify prescriber behaviors and health system characteristics are likely to have success in reducing persistent postoperative opioid use. Accepted for publication October 16, 2018. The authors declare no conflicts of interest. Funding: The PeriOperative Quality Initiative (POQI)-4 consensus conference was supported by unrestricted educational grants from the American Society for Enhanced Recovery (ASER) and the POQI, which have received grants from Baxter, Bev MD, Cadence, Cheetah Medical, Edwards, Heron Pharmaceutical, Mallinckrodt, Medtronic, Merck, Pacira, and Trevena. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://bit.ly/KegmMq). Please see Supplemental Digital Content, Appendix 1, http://bit.ly/2GxzQ4N, for a list of the POQI-4 Workgroup members. Reprints will not be available from the authors. Address correspondence to Michael L. Kent, MD, Department of Anesthesiology, Duke University Medical Center, 3094 #4, Durham, NC 27710. Address e-mail to Michael.kent@duke.edu. © 2019 International Anesthesia Research Society
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I Tweet, Therefore I Learn: An Analysis of Twitter Use Across Anesthesiology Conferences
BACKGROUND: Twitter in anesthesiology conferences promotes rapid science dissemination, global audience participation, and real-time updates of simultaneous sessions. We designed this study to determine if an association exists between conference attendance/registration and 4 defined Twitter metrics. METHODS: Using publicly available data through the Symplur Healthcare Hashtags Project and the Symplur Signals, we collected data on total tweets, impressions, retweets, and replies as 4 primary outcome metrics for all registered anesthesiology conferences occurring from May 1, 2016 to April 30, 2017. The number of Twitter participants, defined as users who contributed a tweet, retweet, or reply 3 days before through 3 days after the conference, was collected. We also collected influencer data as determined by mentions (number of times a user is referenced). Two authors independently verified the categories for influencers assigned by Symplur. Conference demographic data were obtained by e-mail inquiries. Associations between meeting attendees/registrants and Twitter metrics, between Twitter participants and the metrics, and between physician influencers and Twitter participants were tested using Spearman rho. RESULTS: Fourteen conferences with 63,180 tweets were included. With the American Society of Anesthesiologists annual meeting included, the correlations between meeting attendance/registration and total tweets (rs = 0.588; P = .074), impressions (rs = 0.527; P = .117), and retweets (rs = 0.539; P = .108) were not statistically significant; for replies, it was moderately positive (rs = 0.648; P = .043). Without the American Society of Anesthesiologists annual meeting, total tweets (rs = 0.433; P = .244), impressions (rs = 0.350; P = .356), retweets (rs = 0.367; P = .332), and replies (rs = 0.517; P = .154) were not statistically significant. Secondary outcomes include a highly positive correlation between Twitter participation and total tweets (rs = 0.855; P
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Prevalence and Multivariable Factors Associated With Preoperative Cognitive Impairment in Outpatient Surgery in the United States
Preoperative cognitive impairment increases the risk of adverse events after surgery but its prevalence in outpatient surgery has not been defined. We aimed to determine the prevalence and multivariable factors associated with cognitive impairment in individuals who present for outpatient surgery. We used data from the Health and Retirement Study, a longitudinal panel survey of older Americans. Of 1836 participants who reported having outpatient surgery, we found that 16.1% had evidence of cognitive impairment. Significant multivariable factors associated with preoperative cognitive impairment included non-Hispanic African American race, prior stroke, preoperative functional dependence, and lower socioeconomic status and education level. Accepted for publication December 18, 2018. Funding: This work was supported by a University of Pennsylvania Institute on Aging pilot grant. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Timothy G. Gaulton, MD, MSc, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, 310 Blockley Hall, 423 Guardian Dr, Philadelphia, PA 19104. Address e-mail to timothy.gaulton2@uphs.upenn.edu. © 2019 International Anesthesia Research Society
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Contemplating Our Maternity Care Crisis in the United States: Reflections of an Obstetrician Anesthesiologist
No abstract available
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High-Flow Nasal Oxygen Improves Safe Apnea Time in Morbidly Obese Patients Undergoing General Anesthesia: A Randomized Controlled Trial
BACKGROUND: Morbidly obese patients undergoing general anesthesia are at risk of hypoxemia during anesthesia induction. High-flow nasal oxygenation use during anesthesia induction prolongs safe apnea time in nonobese surgical patients. The primary objective of our study was to compare safe apnea time, between patients given high-flow nasal oxygenation or conventional facemask oxygenation during anesthesia induction, in morbidly obese surgical patients. METHODS: Research ethics board approval was obtained. Elective surgical patients ≥18 years with body mass index ≥40 kg·m−2 were included. Patients with severe comorbidity, gastric reflux disease, known difficult airway, or nasal obstruction were excluded. After obtaining informed consent patients were randomized. In the intervention (high-flow nasal oxygenation) group, preoxygenation was provided by 100% nasal oxygen for 3 minutes at 40 L·minute−1; in the control group, preoxygenation was delivered using a facemask with 100% oxygen, targeting end-tidal O2 >85%. Anesthesia was induced with propofol, remifentanil, and rocuronium. Bag-mask ventilation was not performed. At 2 minutes after rocuronium, videolaryngoscopy was performed. If the laryngoscopy grade was I or II, laryngoscope was left in place and the study was continued; if grade III or IV was observed, the patient was excluded from the study. During the apnea period, high-flow nasal oxygenation patients received nasal oxygen at 60 L·minute−1; control group patients received no supplemental oxygen. The primary outcome, safe apnea time, was reached when oxygen saturation measured by pulse oximetry (SpO2) fell to 95% or maximum 6 minutes of apnea. The patient was then intubated. T tests and χ2 analyses were used to compare groups. P
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Questions About the Study by Said Et Al
No abstract available
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Pre-operative assessment of 30-day mortality risk after major surgery: the role of the quick sequential organ failure assessment: A retrospective observational study
BACKGROUND The quick Sequential Organ Failure Assessment (qSOFA) is intended for the assessment of the prognosis and risk of sepsis. It may also help predict the mortality risk of nonseptic patients. OBJECTIVE This study investigated the relationship between pre-operative qSOFA scores and 30-day mortality after major surgery. It also evaluated the predictive value of qSOFA scores combined with the American Society of Anesthesiologists (ASA) physical status and Charlson comorbidity index (CCI). DESIGN A retrospective observational study. SETTING Single tertiary academic hospital. PATIENTS Medical records of patients who underwent major surgery (estimated blood loss >500 ml; surgery time >2 h) between January 2010 and December 2017 were examined. MAIN OUTCOME MEASURES The qSOFA score was measured within 24 h before surgery, and its association with 30-day mortality was analysed using multivariable logistic regression. A receiver-operating characteristic curve analysis was used to investigate the predictive power of the pre-operative qSOFA scores combined with the ASA physical status and with CCI. RESULTS A total of 6336 patients were included in the final analysis, and 91 (1.4%) died within 30 days. The multivariable logistic regression analysis including all covariates indicated that 30-day mortality was 2.43-times higher for the score 1 group than for the score 0 group (P = 0.002), and it was 3.54-times higher for the score at least 2 group than for the score 0 group (P
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Flow-controlled ventilation during ear, nose and throat surgery: A prospective observational study
BACKGROUND Flow-controlled ventilation (FCV) is a new mechanical ventilation mode that maintains constant flow during inspiration and expiration with standard tidal volumes via cuffed narrow-bore endotracheal tubes. Originating in manually operated 'expiratory ventilation assistance', FCV extends this technique by automatic control of airway flow, monitoring of intratracheal pressure and control of peak inspiratory pressure and end-expiratory pressure. FCV has not yet been described in a clinical study. OBJECTIVE The aim of this study was to provide an initial assessment of FCV in mechanically ventilated patients undergoing ear, nose and throat surgery and evaluate its potential for future use. DESIGN An observational study. SETTING Two German academic medical centres from 24 November 2017 to 09 January 2018. PATIENTS Consecutive patients (≥ 18 years) scheduled for elective ear, nose and throat surgery. Exclusion criteria were planned laser surgery, intended fibreoptic awake intubation, emergency procedures, increased risk of aspiration, American Society of Anesthesiologists (ASA) physical status more than III and chronic obstructive pulmonary disease classified as GOLD stage more than II. INTERVENTION Peri-operative use of FCV provided by a new type of ventilator (Evone) via a narrow-bore endotracheal tube (Tritube). MAIN OUTCOME MEASURES Minute volume, respiratory rate, intratidal tracheal pressure amplitude (Δp) and end-tidal CO2 (PetCO2) were recorded every 5 min. All adverse events were noted. Data are presented as median [IQR]. RESULTS Sixteen patients provided 15 evaluable data sets. A minute volume of 5.0 [4.4 to 6.4] l min−1 and a respiratory rate of 9 [8 to 11] min−1 generated a PetCO2 of 4.9 [4.8 to 5.0] kPa. Δp was 10 [9 to 12] cmH2O. Five adverse events were recorded: a tube obstruction due to airway secretions and four tube dislocations (two attributed to coughing, two not study-related). CONCLUSION FCV achieves adequate PetCO2 levels with minute volume and Δp in the normal range. Tritube's high flow resistance may increase the likelihood of tube dislocations if the patient coughs. Although further evaluation is necessary, FCV provides a new option for short-term mechanical ventilation. The successful operation of FCV with narrow-bore tubes contributes to the armamentarium for airway management. TRIAL REGISTRATION DRKS00013312 This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://bit.ly/OBJ4xP Correspondence to Dr. Johannes Schmidt, Department of Anaesthesiology and Critical Care, Medical Centre – University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany Tel: +49 761 270 26390; e-mail: johannes.schmidt@uniklinik-freiburg.de Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://bit.ly/2ylyqmW). © 2019 European Society of Anaesthesiology
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‘May you live in interesting times’: blessing or curse for an intensivist?
No abstract available
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Predicting outcomes in colorectal endoscopic submucosal dissection: a United States experience
Abstract
Objective
Endoscopic submucosal dissection (ESD) allows for en bloc resection of superficial gastrointestinal neoplasms; however, US experience has been limited. We aimed to evaluate our clinical outcomes in colorectal ESD.
Design
This prospective study included consecutive patients undergoing colorectal ESD at a major US center. Demographics, lesion and technical characteristics, outcomes, adverse events, and pathological diagnoses were recorded. Factors affecting resection outcomes and procedure time were evaluated.
Results
77 patients who underwent colorectal ESD were analyzed. Mean colorectal lesion diameter was 49.4 mm. Mean procedure time was 104.7 min, and 97.4% of patients were discharged home on the same day. En bloc, complete, and curative resection was achieved in 97.4%, 97.4%, and 93.5% of colorectal ESD cases. Microperforation and delayed bleeding rates were 1.3% and 3.9%. On univariable analysis, the presence of tattoo adversely affected en bloc resection (p = 0.002), complete resection (p = 0.002), and curative resection (p = 0.008). Prior EMR attempts adversely affected en bloc resection (p = 0.028), complete resection (p = 0.028), and procedure time (p = 0.008). On multivariable analysis, the presence of tattoo predicted failure to achieve curative resection (OR 0.13; 95% CI 0.02–0.98; p = 0.048). Lesion size > 50 mm (OR 3.89; 95% CI 1.13–13.41; p = 0.031), presence of tattoo (OR 9.38; 95% CI 1.05–83.83; p = 0.045), and prior EMR attempts (OR 7.13; 95% CI 1.76–28.90; p = 0.006) predicted procedure time ≥ 90 min. A scoring system was created to predict prolonged ESD procedure time and was externally validated, with AUC 0.78 (95% CI 0.73–0.83).
Conclusion
This study demonstrates the effects of multiple risk factors on resection outcomes and procedure time in colorectal ESD. Tattoo placement and attempted EMR should be avoided for lesions being considered for ESD.
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EUS-guided gastroenterostomy versus enteral stent placement for palliation of malignant gastric outlet obstruction
Abstract
Background
EUS-guided gastroenterostomy (EUS-GE) is a novel procedure for palliation of malignant gastric outlet obstruction (GOO); however, data comparing EUS-GE to enteral stent placement are limited. We aimed to compare clinical outcomes between EUS-GE and enteral stent placement in the palliation of malignant GOO.
Methods
Retrospective analysis of a prospectively collected database on patients who underwent EUS-GE or enteral stent placement for palliation of malignant GOO from 2014 to 2017 was conducted. Primary outcome was the rate of stent failure requiring repeat intervention. Secondary outcomes included technical and clinical success, time to repeat intervention, length of hospital stay, and adverse events.
Results
A total of 100 consecutive patients (mean age 65.9 ± 11.9 years, 44.0% female) were identified, of which 78 underwent enteral stent placement, and 22 underwent EUS-GE. Rate of stent failure requiring repeat intervention was higher in the enteral stent group than the EUS-GE group (32.0% vs. 8.3%, p = 0.021). Technical success was achieved in 100% in both groups. Higher initial clinical success was attained in the EUS-GE group than the enteral stent group (95.8% vs. 76.3%, p = 0.042). Mean length of hospital stay following stent placement was similar between groups (p = 0.821). The enteral stent group trended towards increased adverse events (40.2% vs. 20.8%, p = 0.098). Kaplan–Meier analysis showed decreased stent function in the enteral stent group (p = 0.013).
Conclusion
Compared to enteral stent placement, EUS-GE has a higher rate of initial clinical success and lower rate of stent failure requiring repeat intervention. EUS-GE may be offered for selected patients with malignant GOO in centers with extensive experience.
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In Vitro Characterization of a Potent p53-MDM2 Inhibitor, RG7112 in Neuroblastoma Cancer Cell Lines
Cancer Biotherapy and Radiopharmaceuticals, Ahead of Print.
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Exploring the possibility of endoscopic submucosal dissection for clinical submucosal invasive early gastric cancers
Abstract
Background
The current standard treatment modality for clinical submucosal invasive (cT1b) early gastric cancer (EGC) is surgery. However, there are discrepancies in T staging between pre- and post-operative findings, and in cases of overestimation, patients may lose the opportunity to preserve the stomach. The aim of this study was to analyze surgical outcomes of cT1b EGC and determine the pre-treatment factors favoring ESD.
Methods
Patients who underwent gastrectomy for cT1b EGC with a tumor size of 30 mm or less in diameter and differentiated-type histology were retrospectively reviewed from January 2010 to December 2014. According to the final surgical pathologic results, two groups were classified: patients whose pathologic results qualified for current ESD indication (ESD-qualified group, n = 203) and patients whose pathologic results made them ineligible for ESD (ESD-disqualified group, n = 261). The preoperative clinical characteristics were compared.
Results
Forty-three percent of the patients (203/464) who underwent gastrectomy for cT1b EGC qualified for ESD; their endoscopic lesion tended to be smaller than 20 mm in size and located in the distal part of stomach. In addition, the ESD-qualified group showed a significantly higher proportion of well-differentiated tubular adenocarcinoma on endoscopic biopsy and of the flat/depressed type in the endoscopic evaluation.
Conclusion
Forty-three percent of the patients with cT1b EGC who underwent gastrectomy had a chance to preserve their stomach by ESD. Therefore, pre-treatment factors such as endoscopic lesion size, location, histology, and gross type should be considered for treatment modality selection for cT1b EGC.
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High Rates of Fosfomycin Resistance in Gram-Negative Urinary Isolates from Israel
Microbial Drug Resistance, Ahead of Print.
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Analysis of Phenotypic Variables and Differentiation Between Untypical Crohn’s Disease and Untypical Intestinal Tuberculosis
Abstract
Background
The differentiation between untypical intestinal tuberculosis (UITB) and untypical Crohn's disease (UCD) is a challenge.
Aims
To analyze phenotypic variables and propose a novel prediction model for differential diagnosis of two conditions.
Methods
A total of 192 patients were prospectively enrolled. The clinical, laboratory, endoscopic, and radiological features were investigated and subjected to univariable and multivariable analyses. The final prediction model for differentiation between UCD and UITB was developed by logistic regression analysis and Fisher discriminant analysis on the training set. The same discriminant function was tested on the validation set.
Results
Twenty-five candidates were selected from 52 phenotypic variables of typical Crohn's disease (TCD), UCD, and UITB patients. UCD's variables overlapped with both TCD and UITB. The percentages of tuberculosis history, positive PPD, and positive T-SPOT result in UCD were all significantly higher than that in TCD (11.6% vs. 0.0%, 27.9% vs. 0.0%, 25.6% vs. 4.5%, respectively, P < 0.05). The regression equations and Fisher discriminant function for discrimination between UCD and UITB were developed. In the training data, the area under the receiver operating characteristic of equations was 0.834, 0.69, and 0.648 in the clinical-laboratory, endoscopic, and radiological model, respectively. The accuracy of Fisher discriminant function for discrimination was 86% in UCD and 73% in UITB in the validation data.
Conclusions
Phenotypes of UCD patients in TB-endemic countries may be associated with TB infection history. Fisher discriminant analysis is a good choice to differentiate UCD from UITB, which is worthy of verification in clinical practice.
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Efficacy and Safety of Tenofovir Disoproxil Fumarate in Treatment-Naïve Patients with Chronic Hepatitis B in Korea
Abstract
Aims
To evaluate the efficacy and safety of 144-week tenofovir disoproxil fumarate (TDF) therapy in treatment-naïve chronic hepatitis B (CHB) patients in Korean.
Methods
In total, 579 treatment-naïve CHB patients at 11 medical centers were enrolled retrospective and prospective from September 2015 to January 2016 by design (NCT02533544). We evaluated the complete virologic response (CVR) rate and the renal safety of TDF.
Results
The overall CVR rate was 69.4%, 87.0%, and 89.7% at weeks 48, 96, and 144, respectively. In the HBeAg-positive CHB patients, the CVR rate at weeks 48, 96, and 144 was 61.4%, 83.1%, and 89.6%, respectively. The rates of HBeAg loss and seroconversion at weeks 48, 96, and 144 were 16.6%, 23.5%, 34.1%, and 7.6%, 8.9%, 13.3%, respectively. In HBeAg-negative CHB patients, the CVR rate at weeks 48, 96, and 144 was 82.5%, 93.2%, and 90.0%, respectively. The rate of alanine aminotransferase normalization was 36.9%, 45.4%, and 46.8% at weeks 48, 96, and 144, respectively. Of the CHB patients, 0.9% showed an elevated creatinine (> 0.5 mg/dL from baseline). Age (≥ 60 years) was significantly associated with a decline in renal function at week 144 (P < 0.0001). Comorbidities (diabetes or hypertension) showed the tendency to reduce renal function (P = 0.0624). Hepatocellular carcinoma developed in 10 (1.7%) patients and was related to cirrhosis.
Conclusions
TDF therapy induced sustained viral suppression and had a favorable safety profile over a 3-year period. However, close monitoring of renal function should be mandatory in treating CHB patients receiving TDF, particularly older patients.
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Complications of Long-Term Indwelling Transmural Double Pigtail Stent Placement for Symptomatic Peripancreatic Fluid Collections
Abstract
Background
Endoscopic transmural drainage is performed for symptomatic peripancreatic fluid collections (PPFCs). Long-term transmural double-pigtail stent (DPS) placement is useful in preventing recurrences. There are few reports on the long-term safety of DPS placement. Thus, this study aimed to examine the complications of long-term indwelling DPS for PPFCs.
Methods
Among 53 patients who underwent endoscopic ultrasound-guided transmural drainage for symptomatic PPFCs between April 2006 and March 2017, those followed up for over one year were included. Complications of long-term indwelling DPS were examined retrospectively.
Results
This study enrolled 36 patients [30 men, median age 54 years (range 22–82)]. Walled-off necrosis was present in 22 cases (including 9 disconnected pancreatic duct syndrome cases) and pancreatic pseudocysts, in 14 cases. The median stenting period was 20.9 (range 0.8–142.3) months, and median observation period was 56.2 (range 12.4–147.1) months. Colon perforation due to DPS occurred in 3 cases (8.3%), at 5.8, 17.1, and 33.7 months after indwelling DPS placement; 2 cases developed perforation from the serosal side. In 1 case, the patient was treated surgically, and in 2 cases, the patients underwent endoscopic removal of the stent and showed improvement with conservative treatment.
Conclusion
Long-term indwelling transmural DPS for symptomatic PPFCs poses a risk of intestinal perforation. Thus, if possible, it may be better to avoid long-term placement.
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Presence of Irritable Bowel Syndrome Symptoms in Quiescent Inflammatory Bowel Disease Is Associated with High Rate of Anxiety and Depression
Abstract
Background
Inflammatory bowel disease (IBD; Crohn's disease, CD and Ulcerative colitis, UC) and irritable bowel syndrome (IBS) have overlapping symptoms. Few prevalence studies of IBS in quiescent IBD have used colonoscopy with histology to confirm inactive disease. The aims were (1) to determine the percentage of IBD patients in deep remission whose persistent IBS-like symptoms (IBD/IBS+) would cause them to be classified as having active disease, based on the calculation of Harvey Bradshaw Index (HBI) or UC disease activity index (UCDAI); (2) to identify demographic and disease characteristics that are associated with IBD/IBS+.
Methods
This was a prospective study at a single tertiary care IBD center. 96/112 patients with colonoscopy and histology confirmed quiescent disease consented and completed Rome III criteria for IBS Survey, and the hospital anxiety and depression scale (HADS). Other demographic and disease specific data were collected.
Results
36% (28/77) and 37% (7/19) of CD and UC patients, respectively, met diagnostic criteria for IBS. Significantly higher HBI/UCDAI scores (p = 0.005) and low short inflammatory bowel disease questionnaire (SIBDQ) scores (p ≤ 0.0001) were seen in IBD/IBS+ patients. 29% of patients in deep remission were mis-categorized by HBI/UCDAI as having active disease when they fulfilled Rome III criteria for IBS. Psychiatric diagnosis (OR 3.53 95% CI 1.2–10.2) and earlier onset of IBD (OR 1.056 95% CI 1.015–1.096) were associated with IBD/IBS+. Patients fulfilling IBS criteria had higher hospital anxiety and depression scale (HADS).
Conclusion
IBD/IBS+ affect scoring of IBD disease activity scales and become less useful in guiding treatment plans.
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Variations in the Clinical Course of Patients with Herpes Simplex Virus Esophagitis Based on Immunocompetence and Presence of Underlying Esophageal Disease
Abstract
Background and Aims
Herpes simplex esophagitis (HSE) is the second most common cause of infectious esophagitis and occurs in both immunocompetent and immunocompromised patients. The aim of this study was to reappraise the clinical course of HSE in different patient populations based on degree of immunocompetence and the presence or absence of underlying esophageal disease.
Methods
Patients with histopathologically confirmed HSE identified from the Mayo Clinic pathology database from 2006 to 2016 were included in this study. Relevant demographic, clinical, and endoscopic data were retrospectively reviewed and compared between two cohorts: (a) immunocompromised and immunocompetent patients and (b) patients with and without underlying esophageal disorders.
Results
Forty-six patients were included in the study. The most common presenting symptoms were odynophagia (34.8%) and dysphagia (30.4%). Thirty-three (71.7%) patients were immunocompromised, and these patients who experienced longer duration of symptoms (25.5 ± 23.4 days vs. 7.0 ± 5.5 days, p = 0.04) were more likely to require an extension of treatment course (38.1% vs. 8.3%, p = 0.05) compared to their immunocompetent counterparts. Seventeen (37%) patients had underlying esophageal disease, and these patients were more likely to have concomitant esophageal candidiasis (41.2% vs. 10.3%, respectively; p = 0.01).
Conclusion
Herpes simplex virus causes esophagitis in both immunocompetent and immunocompromised patients. While the disease course appears to be self-limited for all patient populations, clinical and endoscopic differences in the disease presentation and clinical course based on immune status and the presence or absence of underlying esophageal disease exist.
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Primary Sclerosing Cholangitis: A Concise Review of Diagnosis and Management
Abstract
Primary sclerosing cholangitis is a rare, chronic cholestatic liver disease characterized by progressive idiopathic stricturing of the biliary system, typically leading to cirrhosis, end-stage liver disease, and colonic or hepatobiliary malignancy. Its presentation is often that of asymptomatic alkaline phosphatase elevation. When symptoms are present, they typically include fatigue, pruritus, or jaundice. The diagnosis can be confirmed via cholangiography, either magnetic resonance cholangiography (MRCP) or endoscopic retrograde cholangiography if the former is inconclusive. The clinical course is marked by progressive liver disease leading to cirrhosis with its attendant complications of portal hypertension, often including recurrent episodes of cholangitis. Greater elevation in alkaline phosphatase or liver stiffness is associated with worse clinical outcomes. Management includes endoscopic treatment of symptomatic biliary strictures and evaluation of dominant strictures as no adequate medical treatment is available. Multiple medical therapies are under evaluation. Ultimately, liver transplantation may be necessary for management of decompensated cirrhosis or disabling symptoms. There is also a markedly increased risk of cancer, notably including cholangiocarcinoma and gallbladder and colorectal cancers (particularly in patients with colitis). Cancer screening can be done with semi-annual liver imaging (MRCP or ultrasound) and colonoscopy every 1–2 years in those with colitis.
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Associations between Spontaneous Swallowing Frequency at Admission, Dysphagia and Stroke Related Outcomes in Acute Care
Publication date: Available online 5 February 2019
Source: Archives of Physical Medicine and Rehabilitation
Author(s): Giselle Carnaby, Isaac Sia, Michael Crary
Abstract
Objective
To expand the scope of prior spontaneous swallowing frequency analysis (SFA) studies, by evaluating the role of SFA in dysphagia-and stroke-related outcomes at acute stroke discharge.
Design
Period prevalence study
Setting
Tertiary care university hospital
Participants
96 patients with acute stroke.
Interventions
Subjects were screened for dysphagia using SFA. Mode of screening was 24 hours from identified stroke onset. All patients completed dysphagia- and stroke-related assessments. Patients were followed to discharge from acute care and admission SFA was compared to status at discharge.
Results
Lower SFA rates at admission were significantly associated with presence of dysphagia. Lower SFA rates were also associated with persistent dysphagia and restricted diet at discharge. SFA rates were lower for patients with identified aspiration on fluoroscopic swallowing study. Negative stroke-related outcomes from acute care were associated with lower SFA rates including disability at admission, disability and handicap at discharge, and institutionalization at discharge. Regression analysis identified SFA as an independent predictor of the negative composite outcome of death-disability-institutionalization.
Conclusions
SFA not only has a high accuracy of dysphagia identification in acute stroke and relates to dysphagia severity, it is also associated with multiple dysphagia- and stoke-related outcomes from acute care. Early post-stroke dysphagia identification with SFA may lead to earlier and more effective interventions targeted at identified negative stroke outcomes.
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Geriatric Rehabilitation shouldn’t be an Oxymoron: A path forward
Publication date: Available online 5 February 2019
Source: Archives of Physical Medicine and Rehabilitation
Author(s): Jonathan F. Bean, Ariela R. Orkaby, Jane A. Driver
Abstract
Older adults are the fastest growing segment of our population and contribute greatly to the high costs of healthcare. The primary concern among older adults seeking healthcare is maintaining or improving functional independence. This concern is the focus of both Rehabilitative Care and Geriatric Medicine; however, collaboration between these fields can be hampered by a lack of mutual understanding of the fundamental principles of the other field. We describe three steps that can be implemented at an organizational or individual level to bridge the fields of Geriatric Medicine and Rehabilitation, allowing them to better serve older patients. These include: 1) recognizing the interwoven concepts of multimorbidity, function and frailty; 2) communicating with a common language; and 3) synthesizing our knowledge from both fields.
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Stored perfume dynamics and consequences for signal development in male orchid bees
Abstract
Male orchid bees (Euglossini) collect volatiles from their environment to concoct species-specific "perfumes", which are later emitted at mating sites. Intensity, complexity or composition of perfumes may encode age (survival) of a male, but how the individual perfume develops over time needs to be clarified. We investigated chemical changes during storage in leg pockets. We injected a mixture of eight perfume compounds into pockets of Euglossa imperialis and only the two most volatile compounds decreased over 12 days. Using a different approach we found significant shifts in quantities of naturally occurring perfume compounds of Euglossa championi over 10 days, with the strongest decreases (up to 70% peak area) in highly volatile minor compounds, e.g. monoterpenes, and noteworthy increases (up to 40%) in some sesquiterpenoids. Corresponding shifts were observed in legs of dried bees, suggesting that no metabolic activity is required for the observed changes to occur. Our results confirm that male orchid bees are generally good at preserving collected perfumes. However, subtle shifts towards heavier compounds in blends may occur over the lifetime of individual bees, e.g. due to evaporation or in-pocket chemical reaction, with old males acquiring a more pronounced base note in their seasoned perfumes.
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Magnetic Steering of Capsule Endoscopy Improves Small Bowel Capsule Endoscopy Completion Rate
Abstract
Background
Capsule endoscopy is currently available as a noninvasive and effective diagnostic modality to identify small bowel abnormalities, with a completion rate to the cecum between 75.1 and 95.6%. A novel magnetically controlled capsule endoscopy (MCE) system could facilitate passage of the capsule through the pylorus, thereby reducing the gastric transit time (GTT).
Objective
We performed this study to determine whether magnetic steering could improve the capsule endoscopy completion rate (CECR) compared to standard protocol.
Methods
Patients referred for MCE in our center from June 2017 to November 2017 were prospectively enrolled. Magnetic steering of the capsule through the pylorus was performed after standard gastric examination. CECR, GTT, pyloric transit time (PTT), and rapid gastric transit (GTT ≤ 30 min) rate were compared with a historical control group enrolled from January 2017 to May 2017.
Results
CECR was significantly higher in the intervention group (n = 107) than control group (n = 120) (100% vs. 94.2%, P = 0.02), with a significantly shorter GTT (22.2 vs. 84.5 min, P < 0.001) and PTT (4.4 vs. 56.7 min, P < 0.001). Rapid gastric transit rate in the intervention group was significantly higher than the control group (58.9% vs. 15.0%, P < 0.001). There were no statistical differences in the diagnostic yields between the two groups.
Conclusions
Magnetic steering of capsule endoscopy improves small bowel CECR by reducing GTT, adding further support to MCE as a practical tool for noninvasive examination of both the stomach and small bowel.
Trial registration ClinicalTrials.gov, ID: NCT03482661.
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Impact of Angiotensin II Signaling Blockade on Clinical Outcomes in Patients with Inflammatory Bowel Disease
Abstract
Background
Preclinical data demonstrate that activation of the renin–angiotensin system (RAS) contributes to mucosal inflammation, and RAS inhibition by angiotensin-converting-enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) improves colitis in animal models. Less is known regarding the effects of RAS inhibition on clinical outcomes in inflammatory bowel disease (IBD) patients.
Aim
Evaluate the impact of ACEI and ARB on clinical outcomes in IBD.
Methods
Rates of IBD-related hospitalizations, operations, and corticosteroid use were evaluated retrospectively in two groups. First, 111 IBD patients taking an ACEI or ARB were compared to nonusers matched 1:1 based on sex, age, diagnosis, disease location, and hypertension diagnosis. Second, outcomes in a cohort of 130 IBD patients were compared prior to and during ACEI/ARB exposure.
Results
Compared to matched controls, all IBD patients together with ACEI/ARB exposure had fewer hospitalizations (OR 0.26, p < 0.01), operations (OR 0.08, p = 0.02), and corticosteroid prescriptions (OR 0.5, p = 0.01). Comparing outcomes before and during ACEI/ARB use, there were no differences in hospitalizations, operations, or corticosteroid use for all IBD patients together, but patients with UC had increased hospitalizations (0.08 pre- vs. 0.16 during ACEI/ARB exposure, p = 0.03) and decreased corticosteroid use (0.24 pre-ACEI/ARB vs. 0.12 during ACEI/ARB exposure, p < 0.01) during ACEI/ARB use.
Conclusions
IBD patients with ACEI/ARB exposure had fewer hospitalizations, operations, and corticosteroid use compared to matched controls. No differences in outcomes were observed in individuals on ACEI/ARB therapy when compared to a period of time prior to medication exposure.
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International survey of patients undergoing percutaneous coronary intervention and their attitudes toward pharmacogenetic testing
Objective To evaluate perceptions toward pharmacogenetic testing of patients undergoing percutaneous coronary intervention (PCI) who are prescribed dual antiplatelet therapy (DAPT) and whether geographical differences in these perceptions exist. Participants and methods TAILOR-PCI is the largest genotype-based cardiovascular clinical trial randomizing participants to conventional DAPT or prospective genotyping-guided DAPT. Enrolled patients completed surveys before and 6 months after randomization. Results A total of 1327 patients completed baseline surveys of whom 28, 29, and 43% were from Korea, Canada and the USA, respectively. Most patients (77%) valued identifying pharmacogenetic variants; however, fewer Koreans (44%) as compared with Canadians (91%) and USA (89%) patients identified pharmacogenetics as being important (P
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Epithelial Claudin Proteins and their Role in Gastrointestinal Diseases
Our bodies are protected from the external environment by mucosal barriers that are lined by epithelial cells. The epithelium plays a critical role as a highly dynamic, selective semipermeable barrier that separates luminal contents and pathogens from the rest of the body as well as controlling the absorption of nutrients, fluid and solutes (1, 2). A series of protein complexes including the adherens junction, desmosomes, and tight junctions (TJ) function as the principal barrier in paracellular diffusion (3) as well as regulators of intracellular solute, protein and lipid transport (4). TJs are composed of a series of proteins called occludins, junctional adhesion molecules (JAM), and claudins (5, 6) that reside primarily as the most apical intercellular junction. Here we will review one of these protein families, claudins, and their relevance to gastrointestinal and liver diseases. Address correspondence and reprint requests to Joanne C. Masterson, MD, Department of Biology, Maynooth University, Co. Kildare, Ireland (Joanne.Masterson@mu.ie); Glenn T. Furuta, MD, Children's Hospital Colorado, Aurora, CO United States (glenn.furuta@childrenscolorado.org). Received 12 November, 2018 Accepted 26 January, 2019 Supported by: NIH 1K24DK100303 (Furuta GT) and K01-DK106315 (Masterson JC). The authors report no conflicts of interest. © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,
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Measurement of Microvascular Function in Pediatric Inflammatory Bowel Disease
No abstract available
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Deepening the Understanding of Functional and Motility Disorders
No abstract available
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The Simple Pediatric Activity Ultrasound Score (SPAUSS) for the Accurate Detection of Pediatric Inflammatory Bowel Disease
Objective: To identify the most significant ultrasound (US) parameters that predict inflammatory activity and develop a simple US activity score. Methods: Patients were identified through retrospective evaluation of an established database of children with inflammatory bowel disease (IBD). Patients with endoscopy and US within 60 days were included (N = 75). US parameters evaluated included: bowel wall thickness (BWT), mesenteric inflammatory fat, lymphadenopathy and hyperemia. The weighted kappa statistic was calculated to assess agreement between sonographic and endoscopically identified disease location. Using a proportional odds model and ordinal logistic regression, statistically significant (p
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Neonatal Liver Failure with Hemophagocytosis and Skin Rash
No abstract available
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Relation between the amount of daily activity and gait quality in transfemoral amputees
Gait variability is often associated with reduced coordination and increased instability during walking. Especially for patients with musculoskeletal conditions, variability in gait might be associated with the level of daily activity. Therefore, this study examines kinematic variability during walking and the association with daily activity in patients with transfemoral amputation. Therefore, 15 transfemoral amputees, using the C-leg prosthesis of Otto Bock, between 18 and 65 years were recruited during their hospital stay. All patients were able to walk without crutches in everyday life and were familiar with walking using the C-leg system. Gait parameters and data of variability were captured during walking in a gait laboratory by eight infrared cameras (Vicon). Daily activity was assessed using a three-dimensional acceleration sensor of VitaMove. Patients showed variability from 0.84° up to 1.96° in frontal pelvis motion and from 0.9° up to 4.02° in trunk obliquity. The results show a significant correlation between activity and variability in trunk (r=−0.58; P≤0.05) and pelvis (r=−0.63; P ≤0.01) as well as gait velocity (r=0.6; P≤0.05). However, kinematic variability and gait velocity are not related to each other. In conclusion, the results show that kinematic gait variability is associated with the extent of activity and therefore presents an important parameter for assessing amputees' gait quality and daily activity. Correspondence to Janina A. Müßig, MSc, Institute for Biomechanics, Berufsgenossenschaftliche, Unfallklinik Murnau, Prof. Küntscher-Str. 8, D-82418 Murnau, Germany Tel: +49 884 148 4750; fax: +49 884 148 4573; e-mail: janina.muessig@bgu-murnau.de Received September 22, 2018 Accepted December 27, 2018 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
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